Liberating the NHS: some thoughts on the Great Patriotic White Paper 007 of 007.

Well comrades we are almost at the end of the Great Patriotic White Paper and like all those involved in wars of “liberation” are tired. But we must get up and go onward to the final section where hopefully all the threads and loose ends will no doubt come together as do all NHS reforms to produce a “better” and in this case a more “liberated” NHS.

Whatever that will be.

And so we begin section 6 the "Conclusion: making it happen". Onward to “Engaging external organisations”. Does that mean us as GPs by any chance?

It begins with a statement of the obvious and follows with a statement of the less obvious saying that “It provides clarity of purpose: a more responsive, patient-centred NHS, which achieves outcomes that are among the best in the world”.

Sounds like care on the cheap through an increase in bureaucracy that as we write is still being decided (invented?).

“It provides certainty, through a clear policy framework to support that ambition, with increased autonomy and clear accountability at every level in the NHS.”

Did we miss this bit? The NHS Commissioning Board and NICE giving us all of the above?

For what follows is “Much work now needs to be undertaken over the next two to three years, both to manage the transition, as well as to flesh out the policy details”.

So the liberation of the NHS is not being thought of on the hoof?

Oh no for words like “partnership”, “external organizations”, “ shared decision-making” and “choice” follow. Sound familiar?

More “consultation” follows, always a good way of saying the decision has already been made, and look what they will consult about “. . . on strengthening the NHS Constitution . . .”.

Brilliant! Consulting on something that is meaningless to those grunts on the ground. The NHS ran for decades without a meaningless “Constitution”, aka Charter in old money, while certain countries were founded on one. Compare and contrast anyone especially when it comes to quality (not availability) of healthcare.

The new Party goes onto say it will be:

“ . . . seeking views on commissioning for patients (the implementation of the NHS Commissioning Board and GP consortia) . . .”

Curious that when we see patients we are never asked about commissioning by patients only about where can they get the best healthcare.

“. . . local democratic legitimacy in health . . .”

Curious that in a NHS run along Soviet lines since its inception.

“ . . . freeing providers and economic regulation . . .”

No free market agenda here eh comrades?

“ . . . the NHS outcomes framework.”

The care on the cheap new alternative to the former targets now known as “outcomes”. Yet to be decided so no commissioning yet comrades just sit on your hands . . . and wait . . . and wait.

And look at para 6.5 “To support the ownership of the strategy within the NHS . . .” which no doubt means the same “. . . series of consultation activities . . .” as would have happen before the Charge of the Light Brigade in that our comrade Marshals feel that collective “ownership of stratergy” is different from top down imposition of political policy.

Para 6.6 is more management brown smelly bovine excrement until you read “The proper management of financial risk will be of particular importance.”

Someone finally realised that Houston we may have a problem?

On now to “Proposals for legislation”. Another of those cuddly grey box follows which gives a summary of all those layers of bureaucracy that are to be dissolved and all those that will take their place.

In brief no less than the creation a “Public Health Service”, a transference of “local health improvement functions” to “local authorities” known here in the UK as councils with “accountability to the Secretary of State for Health” so once again no Soviet centralized control of NHS plc.

Placing the “Health and Social Care Information Centre”, currently a Special Health Authority on a statutory footing.

Making the “National Institute for Health and Clinical Excellence” a non departmental public body which means no political control on the new 150 targets, sorry “outcomes” comrades.

Establishing the “independent” “NHS Commissioning Board” who just happen to be accountable to the Secretary of State and if you have fought thorough the White Paper thus far you may have wondered how it will manage all its new found roles without the establishment of more bureaucracy than you could imagine.

Establishing a statutory framework for a “comprehensive system of GP consortia”. An excellent idea if as we have here in Northernshire more GPs than can actually find enough work to fill a morning let alone a full day and if every employee of the local Soviet is at worst a Harvard or Yale MBA with distinction as we have locally.

GPs cannot deliver both without compromising either their face to face healthcare or their efficient management of healthcare provision.

And finally establishing “Health Watch”, no passing similarity to a popular crime solving program in the UK to be part of the Care Quality Commission whose first head’s credentials in terms of missing poor quality care are alluded to here by Dr Grumble.

“Reforming the foundation trust model”, “strengthening the role of the Care Quality Commission” and “developing Monitor” anyone see several subtle links to the establishing of Foundation Trusts and events in the county of “Staffordshire” here?

We think there will be a lot of work for toothless tiger orthodontists in amongst these organizations and the mad grab for Foundation status.

And para 6.8 invites you the public to be consulted about how best to manage the changes which brings us on to the next section “Managing the transition”.

The first paragraph states the bleeding obvious that change is a coming big time but for once they:

“ . . . will happen bottom-up, for example GP consortia having greater say and responsibility as rapidly as possible . . .”.

Nice thought but it ain’t happening. Most PCTs, Northernshire’s “enlightened” ones being obvious exceptions, are very conservative and won’t do anything until someone up high says it can happen. They are already blocking any changes for the better for they are still in control.

Para 6.10 is a big one and it illustrates the problem that will inevitably happen more management although it implies less. But then so often is the case that less is often more. Think of fundholding where practices often employed a fund manager in addition to a practice manager.

But commissioning is not fundholding so that will never happen. Or will it?

Section then follows entitled “Timetable for action” which despite all the hype about GPs spending billions really says that nothing much will happen until about 2012. Just look at how long it takes to reinvent the NHS tariffs or are they now currencies? Good to see free (Soviet) markets will flourish under the liberated NHS with centrally fixed pricing to continue.

That will really encourage the GP entrepreneurs or will it be the private sector?

So until autumn 2012 when the NHS Commissionning Board makes its allocations for 2013/14 direct to GP consortia GPs in consortia will be going to lots of meetings but they will have no money to pay the piper.

Worse is that GP consortia cannot hold contracts with providers until April 2013 and as commissioning is said to be based on NICE produced outcomes all 150 of them which won’t be ready until July 2015.

So unless the rules of engagement change dramatically, it looks like for the vast majority of GPs and consortia it is business as usual. Sit in meetings and do nothing useful. The current raft of NHS managers have a 3 year retreat during which they could handicap GP led commissioning for years to come.

Praise be to the Party for its plans to liberate the NHS. He who pays the piper is said to play the tune. Money is also said to be the sinews of war.

Our reading of this is that GP consortia will wait a long time to fight any wars or play any tunes while the Old Guard carry on as usual, and, when we finally get to play, we could be left with a mess by a defeated and by then disbanded Old Guard?

Still fighting the war is often easier than winning the Peace that follows. Back to the day job for quite a long while to come for despite all the hype it looks like business as usual.

We in healthcare on the frontline are going to wait a long time for liberation based on this White Paper and so will our patients.